A 47-year-old homeless woman presented to our ER after bizarre behavior was observed in the shelter. Reportedly, her typical episode began by staring off into space, followed by extremely bizarre and agitated behavior, which involved running into other residents’ rooms. No loss of consciousness, tongue-bite, or urinary incontinence occurred. She had a history of seizures, had been on phenytoin and phenobarbital, but was switched to levetiracetam for unclear reasons. Sodium valproate dose was increased, and she was placed on risperidone by the shelter's psychiatrist. No formal psychiatric diagnosis was made. Multiple psychiatry ER visits were reported because of increased episode frequency. Upon arrival, the patient was pleasant and cooperative. Decompensation of her psychosis was entertained as a diagnosis, and discharge was planned with outpatient follow-up. However, soon she was found walking into another patient’s room, confused and combative.
A typical event was captured on video-EEG. The patient was awake, lying in bed, and talking on the phone. She sat up abruptly, looking confused, holding the phone with her right hand. This was followed by head and eye deviation to the left and left arm extension. Right arm semirhythmic movement was followed by nonpurposeful left hand movement. Post-ictally, she sat up, continued to look confused, and tried unsuccessfully to place the phone back on its cradle. She then began to pull and bite the telephone cord. She eventually ripped the electrode leads off her head. Electrographically at seizure onset there was a change in the background to monorhythmic 6-Hz activity over the left frontotemporal leads (Figure 1).
FIGURE 1.EEG Showing Seizure Onset in the Left Frontotemporal Electrodes